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Abstract: The patient in this case was a 43-year-old Ms. Li, who had symptoms of retrosternal burning, postprandial bloating, and belching for six months, and was not treated with oral acid-suppressing drugs. The symptoms improved significantly after treatment.
Basic information】Female, 43 years old
Disease Type】Non-erosive gastroesophageal reflux disease
Hospital】Tianjin Medical University General Hospital
Date of Consultation】July 2021
Treatment plan】Medication (magnesium aluminum carbonate tablets, mosapride citrate tablets) + dietary modification (less food and more meals)
Treatment period】Outpatient treatment, oral medication for 2 weeks
Treatment effect】Significant improvement of symptoms and recovery of disease
I. Initial consultation
Ms. Li, 43 years old, felt a burning sensation behind her sternum for more than half a year, and had symptoms such as bloating and belching after meals, which occurred 4-5 days a week. Ms. Li reported that she had good living habits, no smoking, drinking alcohol, strong tea and coffee, and no significant abnormality in the previous gastroscopy.
II. Treatment history
The results of esophageal manometry showed low LES pressure, lower than normal relaxation rate, and reduced body clearance. 24-hour pH monitoring showed that the DeMeester score was 0.49, which was less than the upper limit, and there was no pathological acid reflux. The symptomatic findings were considered to be related to reflux, which was predominantly acid-free reflux with mixed and gaseous regurgitant. Combined with Ms. Li’s examination results, the main cause of Ms. Li’s above symptoms was not acid reflux. After communicating with Ms. Li, Ms. Li was advised to eat less and more often, avoid eating too fast, and change the habit of lying down after eating; in addition, she was given magnesium aluminum carbonate tablets and mosapride citrate tablets for oral treatment.
Third, the effect of treatment
After taking the above measures to improve her lifestyle and medication, Ms. Li felt that her symptoms of burning sensation behind the sternum and postprandial discomfort were significantly reduced, her appetite was also improved, her quality of life was significantly improved, and her working condition was gradually improved. After 2 weeks of oral medication, Ms. Li complained that she had no more obvious discomfort symptoms.
IV. Notes
We are glad that Ms. Li has recovered from her illness, but we need to advise her again that the adjustment of her life and diet is also very important. In terms of diet, it is recommended to eat small and frequent meals, avoid eating too much at one time, reduce lying down after meals, take appropriate walks indoors after meals, and limit the intake of caffeine, alcohol and chocolate. In addition, keeping proper exercise and timely adjustment of bad emotions and other behaviors will not only make the treatment of GERD twice as successful, but also reduce the recurrence of the disease.
V. Personal insight
Esophageal reflux disease is widely prevalent in the world and has been on the rise in China in recent years. Various symptoms of esophageal reflux disease recur, and if left untreated, it may bring various complications and affect the quality of life of patients. As in this case, Ms. Li went to the hospital six months after she developed a burning sensation behind the sternum, with postprandial bloating, belching and other uncomfortable symptoms, and her symptoms were relatively serious at this time, but fortunately, she went to the hospital to receive regular treatment to control the continued development of the disease, and won a better prognosis for herself after standardized treatment.